基層照護空間可近性對醫療利用及照護結果之影響

Abstract

研究背景與目的：本研究以「進階式兩階段流動搜尋法(enhanced two-step floating catchment area,E2SFCA)」重新分析台灣本島各鄉鎮每萬人口基層醫師數(醫人比)，並與現行醫人比評估法比較，探討不同地理可近性特質對評估鄉鎮每萬人口基層醫師數之影響。並評估西醫巡迴醫療資源投入後，各鄉鎮市區基層醫療空間可近性改善的程度，及是否確實涵蓋到醫療資源不足區域的人口。接著探討基層照護空間可近性對醫療利用及照護結果之影響。 研究方法：研究目的一與二，使用內政部人口資料、交通部路網數值圖、中央健康保險署醫療執業登記醫師及診所資料、西醫巡迴服務資料，以道路交通時間30分鐘內每萬人口基層西醫師數為基層照護空間可近性的測量指標，利用E2SFCA法對各鄉鎮市區基層醫療空間可近性進行評估，並就傳統及新方法分別得到的可近性指標繪製地圖。研究目的三係以廣義估計方程式(generalized estimating equation, GEE)負二項迴歸、線性迴歸、邏輯斯迴歸，控制社會人口特質、地區特質、鄉鎮地區之群集效應後，檢測可近性對醫療利用、醫療費用、可避免急診及可避免住院之影響。 研究結果：以傳統醫人比評估結果發現，有3個鄉鎮在旅行時間30分鐘內完全沒有診所西醫師資源(佔0.06%)，134個鄉鎮在可近性較低的區域中(佔16.08%)，215個鄉鎮在可近性較適當的區域(佔83.86%)。以E2SFCA分析發現，有16個鄉鎮在旅行時間30分鐘內完全沒有診所西醫師(佔0.53%)，21個鄉鎮在可近性較低的區域中(佔0.82%)，315個鄉鎮在可近性較適當的區域(佔98.65%)。可近性為0及可近性不足的鄉鎮，傳統醫人比方法評估共137個(佔16.14%)，而E2SFCA方法評估只有37個(佔1.35%)，其中的差值100個鄉鎮於E2SFCA方法而言可近性是充足的。兩種方法呈現低度相關(Spearman相關係數為0.13)。在投入巡迴醫療資源後，尚有15個鄉鎮在其旅行時間30分鐘內完全沒有基層西醫師（佔0.49%），有15個鄉鎮在可近性較低的區域中（佔0.49%），有322個鄉鎮在可近性較適當的區域(佔99.02%）。巡迴醫療資源投入前後比較發現，可近性為0及不足的鄉鎮由37減少為30個，人口減少86,305人，比例由1.35%降低至0.98%，共減少0.37%。控制其他變項後，基層照護可近性高，可顯著降低急診次數、急診費用、發生可避免急診風險、可避免急診次數與發生可避免住院之風險。 結論：每萬人口基層醫師數以進階式兩階段流動搜尋法評估較傳統醫人比高，亦較符合現況，兩種方法評估可近性為零之鄉鎮市區有差異。基層照護可近性高，與降低急診次數、急診費用、發生可避免急診風險、可避免急診次數、發生可避免住院風險有關。 關鍵詞：基層照護、空間可近性、進階式兩階段流動搜尋法、地理資訊系統、醫療利用、照護結果

Objectives: The purposes of this study were to explore potential spatial accessibility to primary care in Taiwan through enhanced two step floating catchment area (E2SFCA) and traditional physician-to-population ratio, and to consider medical services of health care resources shortage areas to identify degree of improvement for potential spatial accessibility to primary care, and to evaluate the impact of spatial accessibility to primary care on health care utilization and outcomes. Methods: We used data of population, physician and medical clinic information, travel distance and time, health insurance mobile health care service location. The study subjects were population in the townships of Taiwan. This study calculated physician to population ratio within 30 minutes of travel time as an indicator of spatial accessibility to primary care by using E2SFCA method. Controlled sociodemographic, area factors and township cluster effect with generalized estimating equation to view the relationship between accessibility and the dependent variable. Results: In traditional physician-to-population ratio method, there were 3 townships (0.06%) with no primary care physician within 30 minutes, 134 townships (16.08%) in less accessible areas, and 215 townships (83.86%) in sufficient resources area. In E2SFCA method, there were 16 townships (0.53%) with no primary care physician within 30 minutes, 21 townships (0.82%) in less accessible areas, and 315 townships (98.65%) in sufficient resources area. In traditional physician-to-population ratio method, there were 137 townships (16.14%) with no or less primary care physician, and only 37 townships (1.35%) in E2SFCA method. The difference of 100 townships was in sufficient resources area by E2SFCA method, the two methods show low correlation (spearman correlation coefficient=0.13).After mobile health care service resources were implemented, there were 15 townships (0.49%) with no primary care physician within 30 minutes, 15 townships (0.49%) in less accessible areas, and 322 townships (99.02%) in sufficient resources area.The number of townships with insufficient accessibility was reduced to 30, the number of populations was reduced to 86,305,the proportion was reduced from 1.35% to 0.98%, a total decrease of 0.37%.After controlling for other variables, the accessibility to primary care is high, which can significantly reduce the number of emergency visits, emergency expenses, the occurrence of avoidable emergency risks, the number of avoidable emergency visits, and the risk of avoidable hospitalization. Conclusions: The number of primary care physicians per 10,000 population was evaluated by E2SFCA which is higher than traditional method, and the result of E2SFCA method evaluation more responded to the actual situation, there were differences between the two methods in the evaluation of townships where the accessibility was zero.The high accessibility to primary care was related to the reduction of the number of emergency visits, the cost of emergency, the occurrence of avoidable emergency risks, the number of avoidable emergency visits, and the risks of avoidable hospitalization. Key words: primary care, spatial accessibility, enhanced two step floating catchment area (E2SFCA), geographic information systems (GIS), health care utilization and outcomes